Psychiatry today requires increasingly complex, in-depth and articulated models of understanding of the different levels and factors that can determine people's well-being or their psychological suffering. There is accumulating and robust evidence showing the importance of various individual predisposing factors associated with the emergence and maintenance of mental disorders, including genetic, biological, psychological and cognitive factors. However, hitherto dominant biological psychiatric approaches have neglected the impact of other contextual factors.
Recently, several health and scientific organisations, including the World Health Organization and the journals Nature Mental Health and The Lancet, have called for an assessment of the impact that contextual factors have on mental well-being and the occurrence of mental disorders experienced by individuals and societies. In particular, they have called for value to be placed on studies that report a high impact on mental health of social determinants of health (including factors associated with gender identity, ethno-racial factors, access to social, educational and economic resources, social adversities or social inequality factors), in addition to global and local macroeconomic, environmental, geographical or socio-political factors.
Dramatic examples of the impact of contextual factors on mental health reveal that social disparities or macroeconomic indices of countries (such as the Gini inequality index or the country's socio-economic income index), which a priori might seem distant from people's psychological experiences, have an even greater impact than individual factors in predicting symptoms of depression, anxiety, cognitive impairment and impaired daily function.
Psychiatry thus faces the need to better articulate the multiple levels of evidence on how individual and contextual factors impact mental health. This requires complex models to better articulate the findings of different explanatory models of psychiatry, including biological, psychological, cognitive, social and other models.
In this sense, it is beneficial to revisit some approaches in psychiatry that come close to addressing the multilevel and multifactorial complexity described above. Models such as those proposed by enactive psychiatry could be better structured around the complex articulation requirements of multi-determination of mental disorders. Unlike traditional psychiatry, which tends to categorise mental disorders in terms of specific symptoms associated with individual dysfunctional biological-psychological factors, enactive psychiatry sees mental disorders as maladaptive patterns of interaction between the individual and their environment. This perspective may offer new ways of understanding the aetiology and maintenance of mental disorders, and challenge the reductionist views that often dominate the field of psychiatry. By recognising the importance of the interaction between the individual and their environment, this approach seems to help identify the underlying causes of mental disorders and offer treatments that address not only the symptoms but also the conditions that cause them, assuming multi-determination.
Although approaches such as those proposed by enactive psychiatry can help to integrate multiple levels of determination of psychic suffering, the complexity of the levels of analysis between the individual and the contextual requires the integration of multiple approaches. Thus, it is necessary to promote dialogue between the approaches offered by traditional biological psychiatry, and approaches based on mental well-being and psychodynamic understanding, as well as those offered by social psychology or sociology. Furthermore, it is important to incorporate the knowledge generated from all the aforementioned approaches acquired in our own context.
In addition to all this, there is a need to introduce into complex models new data-driven statistical approaches capable of dealing with multiple levels of complexity, analysing the weight of combined factors, the weight of specific factors, and their multiple interactions and co-determination. Only by allowing dialogue between different approaches to psychiatry will we be able to generate expanded models that manage to cover the complexity of the current evidence in our field, and thus generate better options for understanding psychiatric disorders, fine-tuning support and care strategies, and implementing actions adapted to our reality that impact public policy at national and local level.
